Modified Barium Swallow Study (MBSS) One Gold Standard Assessment

MBSS vs. FEES: It’s Not a War, It’s a Team Effort

Let’s just say it: the dysphagia world has become divided. Team MBSS on one side. Team FEES on the other. Social media might make it feel like you have to pick a side—ride or die with fluoroscopy or scope it till you choke it (just kidding… kinda).

But what if we didn’t have to choose?

What If… It’s Not MBSS vs. FEES, But MBSS AND FEES?

The Modified Barium Swallow Study (MBSS) and Flexible Endoscopic Evaluation of Swallowing (FEES) are both powerful tools in our assessment arsenal. Each has its strengths. Each has its limitations. But here’s the thing: when used together, they offer a more comprehensive understanding of a patient’s swallow function than either one alone.

Much like physicians use both a CT scan and an MRI to assess brain injury, why wouldn’t we use multiple imaging modalities to evaluate something as complex as swallowing?

So Why the Either/Or?

Many facilities only contract with one type of provider—either mobile MBSS or mobile FEES. Hospital systems may limit access to one or the other. But this binary thinking isn’t always in the patient’s best interest.

The research consistently shows that both assessments can reveal similar physiological events, including:

Decreased oral containment
Premature posterior spillage
Decreased hyolaryngeal excursion
Reduced epiglottic inversion
Penetration/aspiration events
Vallecular and pyriform sinus residue
Decreased pharyngeal stripping wave

(Bastian, 1991; Langmore, 2003; Aviv, 2000; Leder, Sasaki, & Burrell, 1998)

The main difference? Residue and aspiration severity tend to be rated higher on FEES (Schatz et al., 1991; Brady & Donzelli, 2013).

So instead of arguing over which one is “best,” we need to start advocating for both.

Want more? You can download The Instrumental Guide to Compensatory Strategies and Maneuvers here. I created this form to help me in my decision making during both MBSS and FEES.

The MBSS: More Than Aspiration

For decades, MBSS has been considered the gold standard in dysphagia assessment (Logemann, 1997). But that doesn’t mean it’s without limitations—or that we’re using it to its full potential.

Let’s Talk About the Why

Too often, the MBSS is used to “rule out aspiration” or “see what’s safe.” But this isn’t just about safety—it’s about physiology. We should be asking:

What’s working?
What’s not?
Where is the dysfunction?
What compensatory strategies change the swallow?

We don’t treat aspiration. We treat the cause of aspiration.

When to Refer

Ask yourself:

Will this change my treatment plan?
Is the patient physically and cognitively able to participate?
Can the facility accommodate the patient (e.g., size, positioning)?

If the answer is yes—refer!

But Wait… Who’s Writing This Report?

The MBSS is only as good as the report it produces. If you’ve ever received one that says “aspirated thin liquids, recommend honey thick,” with no mention of strategy trials or underlying dysfunction—you know the frustration.

A quality MBSS report should include:

Patient positioning
Bolus types and presentation method
Compensatory strategies attempted and their effectiveness
Structural observations
Functional component breakdown
Diagnostic summary
Treatment recommendations

(Palmer et al., 1993; Martin-Harris et al., 2000)

Using a standardized protocol like the MBSImP (Martin-Harris et al., 2008) not only supports consistency but helps ensure thorough documentation.

The Role of the Treating SLP

Communication is everything. The SLP requesting the instrumental study should:

Share patient history and clinical concerns
Recommend consistencies and strategies to trial
Follow up to ensure the report is received

You can’t treat what you don’t understand—and you can’t understand what isn’t reported.

The Treating SLP’s Dilemma

Let’s face it: getting a patient out for an MBSS can be a logistical nightmare. Then you wait… and wait… only to get a two-line report that leaves more questions than answers.

This is why we must:

Advocate for access to both FEES and MBSS
Push for better training and education in instrumental interpretation and report writing
Shift our mindset from “what consistencies are they safe for?” to “what are their physiologic deficits?”

Breaking Down the Swallow (Without Breaking Your Sanity)

When reviewing a report (or completing the study), focus on:

Lip closure → Anterior spillage? Work on labial seal.
Bolus formation → Residue in the oral cavity? Cue those lingual exercises.
Pharyngeal residue → Consider effortful swallows, larger boluses.
Pyriform sinus residue → Could signal PES dysfunction. Think CTAR, Shaker, Mendelsohn.
Penetration/Aspiration → Evaluate hyolaryngeal excursion, airway protection strategies.
Physiology in General →The MBSS gives us the opportunity to look at all of the physiology involved with swallowing and determine what is working and what is not.

Stop Chasing Consistencies

This isn’t a buffet.

We’re not here to trial 15 textures in the hopes one will stick. We’re here to uncover dysfunction, understand physiology, and build a treatment plan.

FEES: A Quick Shout-Out

FEES gives us real-time, color, sensory, secretion, and fatigue data. It’s portable. It’s flexible. It allows for multiple trials without radiation concerns. And yes, you might rate residue as more severe—but that’s not necessarily a bad thing when you’re treating dysphagia. (You know there is also a FEES post if you would like to learn more about FEES.

Final Thoughts: Let’s Be the Experts We Are

Whether you’re team FEES, team MBSS, or both—our role is to be experts in dysphagia. Let’s stop arguing and start advocating. Let’s push for access, improve our documentation, and elevate our profession.

Because when we understand the why, we can change the how.

Are you ready for a deeper dive with even more resources available? Join the Dysphagia Skills Accelerator today. You will get so many great tools with new tools being added all the time! Click here to join now!

Have you ever wanted a way to create a more standardized protocol for your Clinical Swallow Evaluation? Do you often forget or leave out parts of the CSE, you know, the parts that are important for your Plan of Care? You probably need the Clinical Dysphagia Assessment Toolkit if you answered yes. You can get your copy here.

References

APA-formatted references with original links where applicable:

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Bastian, R. W. (1991). Videoendoscopic evaluation of patients with dysphagia: An adjunct to the modified barium swallow. Otolaryngology—Head and Neck Surgery, 104(3), 339–350.
Bonilha, H. S., Simpson, A. N., Ellis, C., Mauldin, P., Martin-Harris, B., & Simpson, K. (2014). The one-year attributable cost of post-stroke dysphagia. Dysphagia, 29(5), 545–552.
Brady, S., & Donzelli, J. (2013). The modified barium swallow and the functional endoscopic evaluation of swallowing. Otolaryngologic Clinics of North America, 46(6), 1009–1022.
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Langmore, S. E. (2003). Evaluation of oropharyngeal dysphagia: Which diagnostic tool is superior? Current Opinion in Otolaryngology & Head and Neck Surgery, 11(6), 485–489.
Leder, S. B., Sasaki, C. T., & Burrell, M. I. (1998). Fiberoptic endoscopic evaluation of dysphagia to identify silent aspiration. Dysphagia, 13(1), 19–21.
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Logemann, J. A. (1993). Manual for the videofluorographic study of swallowing (2nd ed.). Austin, TX: ProEd.
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Logemann, J. A. (1998). Evaluation and treatment of swallowing disorders (2nd ed.). Austin, TX: ProEd.
Martin-Harris, B., Brodsky, M. B., Michel, Y., Castell, D. O., Schleicher, M., Sandidge, J., … & Blair, J. (2008). MBS measurement tool for swallow impairment—MBSImp: Establishing a standard. Dysphagia, 23(4), 392–405.
Martin-Harris, B., Logemann, J. A., McMahon, S., Schleicher, M., & Sandidge, J. (2000). Clinical utility of the modified barium swallow. Dysphagia, 15(3), 136–141.
Palmer, J. B., Kuhlemeier, K. V., Tippett, D. C., & Lynch, C. (1993). A protocol for the videofluorographic swallowing study. Dysphagia, 8(3), 209–214.
Schatz, K., Langmore, S. E., & Olson, N. (1991). Endoscopic and videofluoroscopic evaluations of swallowing and aspiration. Annals of Otology, Rhinology & Laryngology, 100(8), 678–681.
Siebens, A. A., & Linden, P. L. (1985). Dynamic imaging for swallowing reeducation. Gastrointestinal Radiology, 10, 251–253.
Sura, L., Madhavan, A., Carnaby, G., & Crary, M. A. (2012). Dysphagia in the elderly: Management and nutritional considerations. Clinical Interventions in Aging, 7, 287–298.

Dysphagia Ramblings